Between high patient loads in the office, pharmaceutical reps pushing the latest and greatest drugs, and patients wanting a quick fix, lifestyle-as-medicine can sometimes be overlooked. The Nadolsky brothers have taken on a mission to change that. This monthly column will review studies in the field and offer tips on how to incorporate new knowledge into practice.

In our last column, we highlighted just some of the major medical guidelines that emphasize lifestyle as first-line medicine, including the integral role of exercise. It's not a secret that exercise is medicine, but there's a perception of disconnect between what's recommended and what's prescribed.

Physicians may not be comfortable prescribing exercise and we certainly aren't doing it as often as necessary, for many reasons, including education, time, and appropriate reimbursement. Fortunately, there are many physicians and aspiring physicians who are passionate about making exercise and physical activity one of the cornerstones of healthcare.

Jordan Feigenbaum is a fourth-year medical student at Eastern Virginia Medical School who is leading a movement of trainees who are focused on exercise-as-medicine. Feigenbaum has already had a successful career in fitness, and runs the website BarbellMedicine.com. We spoke with him about his ideas for incorporating a gym into primary care.

Nadolskys: Jordan, thanks so much for talking about your ideas with us today. What is the issue you see that is most alarming in regards to the prescription of exercise in medicine (specifically primary care) today?

Feigenbaum: Thanks for the invite. I feel privileged to get to talk about these ideas with like-minded medical professionals. With respect to exercise prescription in primary care, I'd make the argument that there are actually multiple alarming issues. When looking at the published data on the topic, we can see that exercise recommendations in the primary care setting are (a) usually wrong, [since only about] 12% of physicians actually know the current American College of Sports Medicine (ACSM) guidelines, (b) not given very often, as 6% of those 12% actually discuss exercise with patients, and (c) have barriers to implementation, as cited in the numerous studies addressing this issue, -- i.e., there's not enough time to discuss it, it's not reimbursable, or there's not enough knowledge on the topic.

Feigenbaum: In general, I think that clinicians are aware of the benefits of exercise on things like mortality, quality of life, etc., but probably not up-to-date on the latest data regarding specific modalities of exercise and their applications. Similarly, I do think there is a knowledge gap as far as knowing what the current recommendations are, what specific modalities have shown to be efficacious in both clinical and research settings -- e.g., resistance training and high-intensity interval work, and the safety of such interventions.

For instance, data continue to mount supporting the benefits of strength training with respect to preservation of functional status, osteoporosis prevention, and among other things, reduction in all-cause mortality. As you stated, cardiorespiratory fitness is important too, though resistance training in and of itself tends to improve these metrics also. Also of note, the efficacy of high-intensity interval training has been elucidated in many populations such as the obese, metabolic syndrome, and COPD patients, and those requiring cardiovascular rehabilitation.

Overall, I think the exercise recommendations that are given -- if they're given at all -- are overly cautious, not evidence-based, and lacking in specificity. I'd love if there were more healthcare professionals recommending resistance training as a primary exercise intervention, for instance. One of the instruments I helped develop to address these issues is an easy-to-read rate of perceived exertion (RPE) scale that correlates the desired intensity of exercise with a specific type of exercise. The scale has been previously validated, though putting it together with specific modalities and the current ACSM recommendations had not been done prior to this. It can been seen here.

Nadolskys: We've always dreamed of somehow incorporating a gym into a medical practice, and certainly primary care is the area of greatest need. Tell us about your ideas that you've developed for accomplishing such a feat.

Feigenbaum: Excellent question and to be honest, my solution is continually evolving as I simultaneously gain more experience in the medical field and the fitness industry. At the present time, my solution centers around building a practice that integrates exercise, nutrition, sleep, and other "lifestyle" modifications with modern medicine, with the goal being an overall reduction in healthcare use and improvement in quality-of-life for the patients.

Once in clinical practice, I fully expect that my assessment will include discussion of the patient's current training level and that my plan will have specific recommendations reflecting this assessment. It's not enough, in my opinion, to just recommend people do these things. As social psychology experiments have shown, the more barriers there are to doing something, the less likely people are to do it. So yes, I want a legitimate strength and conditioning gym attached to the office staffed with competent coaches where patients will have regular appointments as part of their personal health improvement plan.

Additionally, I want to build a community within the practice using the gym. By building strong social relationships in that unique environment, I think we can improve compliance and accountability in my patient population. Both anecdotal and scientific evidence suggests improved compliance with the aforementioned training modalities, thus likely lowering the dropout rate and improving patient retention and, likely, the results. This obviously helps from a business model standpoint in terms of advertising. The members of the practice who love it so much make it attractive to other potential patients, improving the viability of the business model.

Nadolskys: That sounds great, but how can you sell more people on the idea?

Feigenbaum: In my mind, there are two major groups of people that need to be sold here. One group are practitioners, i.e., those in the trenches currently. How can we sell them on the idea that preventative medicine as proposed here is useful in the context of lowering healthcare costs, improving outcomes, while still being a viable business model? For that group, I think the main thing we have to do is simply show that it works. My current plan is to follow outcomes of people enrolled in the "health maintenance plan" and see how much money we spend on healthcare, how their quality of life is, and measure their health and disease markers. If 5- and 10-year outcomes show an improvement over standard of care, we spend less money or even the same, then that's a powerful idea right there. Add to that a viable business model, and perhaps family practice just became a lot more attractive to those who would otherwise subspecialize in order to pay off high student loan debt or make a high income.

Nadolskys: Is this model geared more toward a concierge practice, or would it be viable for for those working for a corporate healthcare system taking insurance and those accepting Medicare/Medicaid? Also, do you have any thoughts on the YMCA programs or others like it?

Feigenbaum: I think this model lends itself to a concierge, direct-primary care, or hybrid model fairly readily. The preventative model I have been describing will include additional services such as access to a fitness facility, a good coach, and other providers. I don't think I'll have a definitive answer for the possible business models until after I do it, but based on my experience in the fitness industry, I suspect there will be multiple ways to implement this model.

As for the Silver Sneakers program you mentioned and others like it, I think they are a step in the right direction, certainly. That said, my main hang-up is always the quality of the product -- in this case, the fitness, nutrition, and lifestyle interventions rendered by these companies. Unfortunately, there are just not a lot of exercise professionals, i.e., legitimate strength and conditioning coaches, who provide safe yet efficacious services to the masses. In general, the good coaches work for themselves in small private settings because they know their time is valuable and don't want to subject their clientele to a suboptimal training environment. That can include the facility being overcrowded, a lack of correct equipment, or having restrictions on what they can do with their clients because of what an executive or other professional deems as "appropriate," which is typically not evidence-based or based on practical experience.

I don't mean to sound so disenfranchised with the current commercial fitness and training industry, but the truth is that most of the trainers hired by commercial gyms are there to babysit and generate additional revenue for the gym instead of providing a high-quality, effective service.

Moreover, the typical commercial gym business model is diametrically opposed to that of the model that I and other like-minded coaches are trying to cultivate. The commercial gym wants to sign up as many new members as they can at $19.99 a month, which is, of course, packaged in a 2-year contract. The kicker here is that they don't want that member to show up for very long because if a significant amount of new members did, the gym would quickly run out of room and have to expand, thus subjecting the owner to forking out additional overhead for extra space and equipment. If new members sign on the dotted line but only work out a handful of times before going rogue, the gym benefits by getting that monthly payment without having to support additional members actually using the facility.

As for physicians currently in practice, I think the easiest thing to do would be to find out who the good strength and conditioning professionals are in the area and build a relationship there. Referring patients for exercise interventions is a start, with group classes at specific times being a mutually beneficial situation for the patient and coach. Imagine a scenario where a group of primary care physicians organize "fitness challenges" that last 12 weeks at a time. Patients can sign up for a nominal fee to cover the cost of a group class, and they all get coaching by a trained professional.

Over time, it would be possible to get a big chunk of a physician's practice to start doing legitimate exercise while integrating the gym into the clinic. The next phase of this scenario is obvious. When the amount of patients who participate in the clinic-organized exercise program has reached the tipping point that enough revenue is being generated by the third-party gym facility, it's time to build the gym adjacent to the clinic and hire the strength coaches to come staff it in-house.

As an aside, it's currently possible to bill for the exercise counseling using code V65.41 and V65.3 for dietary counseling.

Nadolskys: A potential barrier we see is that most doctors are not business people and perhaps this is daunting. We looked into gym ownership in the past and the business logistics were formidable.

Feigenbaum: That's another excellent point. Besides the problem with physician knowledge base, it would appear that the materials I provided above regarding patient education and setting up an alliance with a good local training facility could help any business person set up something like this and make it work.

At the present time, my thoughts are that this would likely fail unless the person/people involved had a wealth of experience in both the fitness industry and the medical field along with a keen business sense. It's going to take a lot of effort and trial-by-fire to iron out all the kinks, so someone is going to have to blaze a new trail passionately.

My plan is to be that person after I complete residency for primary care and create a turn-key model for others to join forces. Of course, this is all pending successful outcomes in addition to the viable business model. If the outcomes aren't there then I'll have to retool my approach, as any physician-scientist would when presented new information.

Nadolskys: We think this idea is really interesting and could blend excellent preventive medicine with a direct-payment model that could be fulfilling to a primary care physician. We did some research and found an increasing number of health insurances that offer full or discounted rates on gym memberships for patients. For the practitioners who don't want to open their own gym and still want to get their patients into a gym, make sure to mention this to your patients and suggest they call their insurance company to find out if this is something they cover. Additionally, we need to promote increased frequency of exercise prescription writing.

For more information, we recommend checking out this interview with Jordan Metzl, MD, author of The Exercise Cure, about incorporating exercise prescription in your practice.

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